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Priniclpes Of Anesthesia > exam 3- chronic pain > Flashcards

exam 3- chronic pain Flashcards

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1
Q

Chronic pain definition

A

Uninterrupted persistent pain lasting for 3 months or more

Determination of source is not always clear

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2
Q

Things that go along with chronic pain

A

povrty, despair, suicide, divorce, interferes with ADLs, economic impact

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3
Q

Chronic pain classification

A

malignant or non malignant

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4
Q

Chronic pain treatment goal

A

improve ADLs, enhance function, multidisciplinary approach to treatment

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5
Q

Pathophysiology of chronic pain (4 steps)

A
  1. Afferent signals amplified
  2. descending modulation from dorsal horn pathway is decreased
  3. prolonged stimulation, inflammation and nerve injury can sensitize pain transmission fibers
  4. Death of inhibitory cells and/or cause structural neuroplastic changes
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6
Q

Central mechanisms of chronic pain (2)

A
  1. chronic inflammation
  2. hyper excitability of second order neurons in the dorsal horn
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7
Q

Primary neurotransmitter released by primary afferent in the dorsal horn

A

glutamate

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8
Q

Glutamate role in chronic pain

A

excites receptors, causing influx of calcium into cell –>increases second messengers such as protein kinase and phospholipase

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9
Q

Glutamate activates (2)

A
  1. NMDA receptor (among others)
  2. Substance P and CGRP to bind
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10
Q

Activation of secondary messengers from glutamate binding:

A

Up - regulation and hyperexcitability

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11
Q

Up-regulation and hyper excitability of NMDA receptors causes

A

Long term neuronal plasticity and eventually gene transcription changes = sensitization and chronic pain states

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12
Q

What is wind up

A

abnormal response and chronic pain sensation

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13
Q

What causes wind up

A

Repetitive stimulation from chronic inflammation or nerve damage

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14
Q

2 phases of windup:

A
  1. hyperalgesia (less and less stim required to initiate pain
  2. FIbers that don’t normally carry painful stimulation are recruited and start transmitting pain
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15
Q

Chronic pain can lead to

A

psychological dysfunction

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16
Q

Prevention of chronic pain and wind up

A

Treat underlying conditions

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17
Q

In windup, synchronous volleys of affarents produce

A

long lasting synaptic potentials

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18
Q

Windup is the repetitive activation of ______ which______

A

C-fibers, which increases magnitude of evoked responses

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19
Q

Windup leads to

A

central sensitization

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20
Q

Central sensitization is

A

enhanced excitability of dorsal horn neurons

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21
Q

Central sensitization contributes to

A

hyperalgesia

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22
Q

Types of chronic pain (4)

A
  1. neuropathic pain
  2. nociceptive pain
  3. somatic pain
  4. visceral pain
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23
Q

Neuropathic pain definition and manifestations

example

A

pain radiates from a damaged nerve along dermatome

manifestations: intense burning sensation, allodynia. (exaggerated pain repsonse)

ex. shingles

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24
Q

Complex regional pain syndrome s/sx

A

spontaneous pain, hyperalgesia, allodynia, trophic, sudomotor, vasomotor abnormalities, active/passive movement disorders

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25
Complex regional pain syndrome treatment (3)
Sympathetic block, meds, spinal cord stimulator
26
Complex regional pain syndrome meds
gabapentin, ketamine infusion, memantine
27
Complex regional pain syndrome type 1 (including pathophys)
Reflex sympathetic dystrophy cause: trauma, surgery, neck injury, female
28
Complex regional pain syndrome type II (including pathophys)
Causalgia cause: nerve injury (i.e. nerve cut in surgery)
29
Somatic pain originates in
arms, legs, face, muscles, tendons, extrinsic areas of body
30
Somatic pain is triggered by
acute injury or chronic disease (cut, bruise, arthritis, joint injury)
31
Visceral pain and presentation
internal organs recepted as referred pain Presentation: N/V, jitteriness
32
Inflammatory nuerochemical substances and reason
Bradykinin, histamine, substance P Serves to protect and prevent further damage
33
Chronic post-surgical pain risk factors:
1. preoperative pain 2. comorbidities/autoimmmune 3. secondary gain
34
Chronic postsurgical pain treatment goal
reduce central sensitization
35
Methods to reduce central sensitization in postsurgical chronic pain
Pre-op treat (meds and block) meds: NSAIDS/ketamine
36
Post op control of chronic postsurical pain (3)
1. Antidepressants 2. PO pain meds: ST opioids, anticonvulsants, topical agents, NMDA antagonists 4. Topical agents
37
Chronic postsurgical pain nature
neuropathic without identifiable nerve injury. Still possible nerve compression/damage
38
Common Chronic postsurgical pain surery:
Thoracotamy or thoracic penetration of some sort)
39
Pharmaceuticals MOA in chronic pain (2)
1. assist in returning body to normal function (reduce cycle) 2. Treat pain perception only w/o reducing dysfunctional cycle of chronic pain
40
NSAIDS MOA
COX blocking-->reduces release of PGs
41
Best to reduce inflammation
COX-2 is better than nonselective COX inhibitor
42
Aspirin
nonselective COX inhibitor
43
Aspirin side effect
prolonged platelet aggregation
44
Multimodal treatment options for chronic pain (8)
1. Meds 2. Rehab 3. Psychology 4. Interventional pain management 5. implantable therapies 6. Complementary/alternative treatments 7. Nutrition counseling 8. Vocational Counseling
45
Opioids act in the
CNS, not periphery (not effective in chronic pain's main source of pain) can be used for short term releif
46
Opioid induced hyperalgesia
Sensitization to painful stimuli d/t opioid exposure (hyperalgesia) May be same or different pain from original pain
47
Chronic opioid therapy and preoperative pain management (3)
1. Know doses, don't d/c or if you must, give adjunct 2. Consider intrathecal or epidural infusion and continue perioperatively 3. benzos
48
Methadone use
1.Preemptive analgesia for acute pain management 2. opioid addiction txmt *need EKG - prolonged QT
49
Suboxone use
get off chronic opioids - prevents w/d and raving
50
Suboxone MOA
Blocks other opioids from binding
51
Suboxone caution
NEVER give versed or benzos: can throw them back into addiction
52
Chronic opioid therapy patients - perioperative pain management (5)
1. Increase dose 2. avoid opioid antagonist or agonist-antagonist (w/d) 3. Nonopioid analgesic adjuncts (ketamine, clonidine, dex) 4. Magnesium 2-3 g 5. regional/local
53
Gabapentin (antivonvulsant) in chronic pain - MOA
blocks alpha 2 delta of Ca+ channels in CNS, prevents excitatory neurotransmitter release overall decrease in neuronal excitation
54
Perioperative pain management in COT (4)
1. Regional 2. IV PCA (feeling of control) 3.pain specialist 4.Monitory for respiratory depression
55
Ketamine MOA
blocks NMDA = treatment and prevention of chronic pain
56
Pros of ketamine perioperatively
1. lowers opioid requirement (even at low dose 0.25-0.5 mg/kg)
57
Ketamine should be used at a _____ because _____
low dose (0.5 mg/kg or less), because it minimizes N/V, hallucinations.
58
Cylobenzaprine (flexeril) result
Relief of muscle spasm
59
Cyclobenzaprine (flexeril) is chemically related to
amtriptyline (antidepressant)
60
NSAID topical agents pros (2)
1. absorption better than PO 2. Continuous deliver may. help reestablish a noral pathway
61
Sleep is important for
healing and cell regeneration promote sleep in chronic pain!KAn
62
Issue with sleep aid meds
interrupt rapid eye movement, disrupting quality of sleep
63
Antidepressant and chronic pain MOA
Block reuptake of serotonin and NE = increase their availability Improved mood = increased compliance, decreased opioid use
64
in chronic pain, Tricyclic antidepressants used for (3)
1.postherpetic neuralgia 2. HAs 3. fibromyalgia
65
SNRIs are preferred in
those with cardiac disease
66
Lidocaine patch MOA
local Na+ channel blockade
67
Capsaicin cream MOA
reduces nerve fiber density w/ daily application
68
Mexiletine is
PO lidocaine
69
lidocain IV helps with
resistant neuropathic pain syndrome
70
Lidocaine infusions show _____ in treatment with neuropathic pain
relief equal to morphine, gabapentin, amtriptyline
71
Dexmedetomidine MOA (3)
1. Peripheral analgesia effect 2. central analgesia effect 3. Local analgesia effect
72
Dexmedetomidine peripheral analgesia effect MOA
inhibits A delta and C fibers
73
Dex central analgesic effect MOA
Depolarizes blue plaque in descending pathway in spinal cord in pre-synaptic pathway inhibits release of substance P -->inhibit spinal cord transmission --> terminates pain signal
74
Dex local analgesia effect MOA
modulation of hyperalgesia - alpha2 receptor stimulator *add to peripheral nerve block
75
SE of dex in peripheral nerve block
N/V, resp depression, itching
76
Corticosteroids in chronic pain
anti-inflammatory effect: inhibit phospholipase A2 = prevent release of arachiadonic acid overall decrease in inflammatory cytokines
77

Priniclpes Of Anesthesia (19 decks)

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